Uncovering high rates of unsafe injection equipment reuse in rural Cameroon: validation of a survey instrument that probes for specific misconceptions.

BACKGROUND: Unsafe reuse of injection equipment in hospitals is an on-going threat to patient safety in many parts of Africa. The extent of this problem is difficult to measure. Standard WHO injection safety assessment protocols used in the 2003 national injection safety assessment in Cameroon are problematic because health workers often behave differently under the observation of visitors. The main objective of this study is to assess the extent of unsafe injection equipment reuse and potential for blood-borne virus transmission in Cameroon. This can be done by probing for misconceptions about injection safety that explain reuse without sterilization. These misconceptions concern useless precautions against cross-contamination, i.e. "indirect reuse" of injection equipment. To investigate whether a shortage of supply explains unsafe reuse, we compared our survey data against records of purchases. METHODS: All health workers at public hospitals in two health districts in the Northwest Province of Cameroon were interviewed about their own injection practices. Injection equipment supply purchase records documented for January to December 2009 were compared with self-reported rates of syringe reuse. The number of HIV, HBV and HCV infections that result from unsafe medical injections in these health districts is estimated from the frequency of unsafe reuse, the number of injections performed, the probability that reused injection equipment had just been used on an infected patient, the size of the susceptible population, and the transmission efficiency of each virus in an injection. RESULTS: Injection equipment reuse occurs commonly in the Northwest Province of Cameroon, practiced by 44% of health workers at public hospitals. Self-reported rates of syringe reuse only partly explained by records on injection equipment supplied to these hospitals, showing a shortage of syringes where syringes are reused. Injection safety interventions could prevent an estimated 14-336 HIV infections, 248-661 HBV infections and 7-114 HCV infections each year in these health districts. CONCLUSIONS: Injection safety assessments that probe for indirect reuse may be more effective than observational assessments. The autodisable syringe may be an appropriate solution to injection safety problems in some hospitals in Cameroon. Advocacy for injection safety interventions should be a public health priority.

Injections that kill: nosocomial bacteraemia and degedege in Tanzania.

CONTEXT: In Tanzania and some other African rural settings, a traditional proscription of injections for the treatment of cerebral malaria (degedege) stems from parents' fear that injections will kill a child with fever and convulsions. The re-use of injection equipment in rural clinics is associated with bacterial contamination even where sterilization is practiced to prevent HIV transmission. A secondary infection with bacterial sepsis is indistinguishable from non-responsive malaria on clinical examination, and may be a significantly under-reported adverse event in rural Tanzania. In a prospective survey of patients whose venous catheter was culture positive on removal, 61% developed bloodstream infections. ISSUE: Parents report having witnessed a child's death following an injection for the treatment of fever and convulsions in rural Tanzania, and some traditional healers who would refer a child with uncomplicated malaria for Western biomedical treatment are convinced that injections are fatal for a child with convulsions. Injection drug users learn aseptic technique to avoid what is called a 'dirty hit', a systemic infection that is felt immediately after injecting, indicating sudden deterioration is likely in a sick child if an IV injection is unsafe. Community mistrust of injection providers has been too casually attributed to superstition; to address parents' concerns, injection safety should be a priority in rural health services. Intravenous injections carry a 0.2% risk of acute bacteremia when given with unsterile equipment, while unsafe infusions carry a 3.7% risk of infection, much greater than the risk from intramuscular injections of vaccine. Sepsis should be considered an important adverse event in the management of severe malaria, but the diagnosis of nosocomial bloodstream infections is a challenge in hospitals that cannot culture for bacteria. When the auto-disable syringe was introduced, patient safety improved at a Tanzanian district hospital; a reduction in the burden of serious secondary infections large enough to reduce the average inpatient length of stay was observed. Nosocomial bloodstream infections are a common cause of fever in Tanzanian hospitals. In Tanzania, bacteremia is sometimes associated with more deaths in hospitals than malaria. LESSONS LEARNED: Although other obstacles to appropriate treatment for malaria may be more important in rural Tanzania, the belief that injections will kill a child is suggestive of avoidable adverse events. The intensity of malaria treatment in rural areas and frequent recourse to informal sector health care presented a significant challenge for the prevention of adverse events including sepsis and HIV transmission. A household survey in rural Tanzania found that 27% of malaria treatment occurs at drug stores, and 30% of patients seek treatment at a general shop. A majority of rural patients evaluated for malaria in the formal sector have taken chloroquine before coming to the clinic. A new national injection safety policy banning the import of non-auto-disable syringes prevents injection equipment re-use in the informal sector. Improving injection safety in rural Tanzania through the introduction of auto-disable syringes will ensure that parents have nothing to fear from quinine injections and infusions that are usually life saving.

Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review.

The reuse of injecting equipment in clinical settings is well documented in Africa and appears to play a substantial role in generalized HIV epidemics. The U.S. and the WHO have begun to support large scale injection safety interventions, increased professional education and training programs, and the development and wider dissemination of infection control guidelines. Several African governments have also taken steps to control injecting equipment, including banning syringes that can be reused.However injection drug use (IDU), of heroin and stimulants, is a growing risk factor for acquiring HIV in the region. IDU is increasingly common among young adults in sub-Saharan Africa and is associated with high risk sex, thus linking IDU to the already well established and concentrated generalized HIV epidemics in the region. Demand reduction programs based on effective substance use education and drug treatment services are very limited, and imprisonment is more common than access to drug treatment services.Drug policies are still very punitive and there is widespread misunderstanding of and hostility to harm reduction programs e.g. needle exchange programs are almost non-existent in the region. Among injection drug users and among drug treatment patients in Africa, knowledge that needle sharing and syringe reuse transmit HIV is still very limited, in contrast with the more successfully instilled knowledge that HIV is transmitted sexually. These new injection risks will take on increased epidemiological significance over the coming decade and will require much more attention by African nations to the range of effective harm reduction tools now available in Europe, Asia, and North America.